Upper GI Disease Where we are Dr Gary Mackenzie Consultant Gastroenterologist

Introduction Reflux –Complications Barrett’s Surveillance and new NICE Guidance Schatzki Rings and Eosinophilic Oesophagitis Local service development Capsule Endoscopy: The first two years

Reflux

Treatment of reflux PRN Antiacids PRN PPI/ H2 Blockers Regular PPI, (?BD ?Nexium) OGD Addition of antacid for breakthrough (Gaviscon Advanced) Addition of ranitidine for nocturnal symptoms pH/manometry. Consider Surgery Self medication General Practice Gastroenterologist Surgeons

Complications of reflux disease

Peptic Strictures Relatively long history Symptoms not intermittent Often history of reflux May require multiple dilatations Risk is 2% of Perforation

Peptic Strictures

Barrett’s Surveillance

Barrett’s

Confers an increased risk of oesophageal cancer of x There is a rapidly rising incidence Dissappointing results from surveillance programs (RCT currently)

Barrett’s Surveillance Discussion of risks and benefits Quadrantic biopsies every 2cm On PPI. Histology: –No dysplasia: 2yearly –Indeterminant: Re-evaluate 3months then if no dysplasia 2years –LGD: 6 monthly intervals –HGD: Repeat immediately and discuss MDT

Current Treatment Treatment dose of a PPI Consider NSAIDs/ Aspirin Surveillance Radiofrequency ablation for HGD Oesophagectomy for Cancer

Radiofrequency Ablation for High Risk Patients Recent NICE Guidance £6000 vs £21000

Radiofrequency Ablation The device: –Essentially a novel form of bipolar electrocoagulation –It circumvents previous problems of treating extended areas and controlling the depth of the burn

Radiofrequency Ablation HALO 360 Device:

After treatments

Schatzki Rings and Eosinophilic Oesophagitis

Schatzki Ring Fibrous band in the distal oesophagus Causes intermittent dysphagia Predisposed to by: –Reflux –Eosinophilic oesophagitis 80% disrupted by quadrantic biopsies Some require dilatation

Schatzki Ring

Eosinophilic Oesophagitis Infiltrate of eosinophils into the oesophageal wall Not to be confused with reflux Greater than 10 per HPF Responds to dry swallowed steroid inhaler

Local Service Development

Local Service development Manometry and pH testing Support other services: –Upper GI surgery –Gastroenterology –Respiratory medicine Long current waits: –Guildford approx. 6 months –Brighton now only take pre-op referrals

HRM system

24 hour pH catheter

Normal Study

Significant acid reflux

HRM catheter

HRM: Low LOS Pressure

HRM: Nutcracker Oesophagus

HRM: Post fundoplication dysphagia NSSD Poor LOS Relaxation

Capsule Endoscopy: The first 2 years

Recap Novel way of imaging the small bowel –11mm x 25mm long. –Connects using ECG leads –Endoscopic quality pictures of the small bowel

Indications GI Bleeding –Overt with normal OGD and Colonoscopy –Occult often presenting as recurrent Iron Deficiency Anaemia Abdominal Pain –Diagnosis of Crohn’s Disease –Unresponsive Coeliac disease

Small bowel GI Bleeding

Crohn’s Disease

Cancers

Results so far… 112 studies in 2 years –7 active bleeding subsequently treated. –2 Small bowel cancers and 2 small bowel polyps. –16 patients with Crohn’s Disease. –36 other bleeding abnormalities: NSAID injury, angiodysplasia –4 unresponsive Coeliac Disease –1 small bowel benign stricture –Rest minor abnormalities or normal. 68/112 changed management

Increasing strong department Bringing more services locally Provide better GI services Summary